2018 Plan Highlights |
Co-pay/Co-insurance |
---|---|
Preferred Gold with Part D monthly premium with prescription drug coverage |
$172.20 |
Preferred Gold with Part D monthly premium for EPIC subsidy members (Assumes EPIC premium assistance) |
$133.20 |
Preferred Gold without Part D monthly premium without prescription drug coverage** |
$59.20 |
Annual Out-of-Pocket Max for your protection (once met, MVP pays 100% of covered services) | $6,700 Excluding acupuncture, eye wear, and Part D drug costs |
PCP co-pay |
$15 |
Specialist co-pay |
$30 |
Inpatient Hospital co-pay |
$350/day for days 1-5; $0 for days 6+ |
Emergency Room Care (Worldwide Coverage) |
$80 |
Urgently Needed Care (Worldwide Coverage) |
$50 |
Lab | $10 |
X-rays |
$30 |
Other radiology services (CT scan, PET scan, MRI) | $60 |
Skilled nursing facility |
$0/day for days 1-20, |
Outpatient services co-pay |
$100 Ambulatory, $225 Outpatient Hospital |
Home care |
Covered in full |
Diabetic blood glucose test strips |
10% co-insurance for OneTouch, FreeStyle, and Precision brands
|
TruHearing® Hearing Aid Benefit | $499 or $799 co-pay per aid with Part D $699 or $999 co-pay per aid without Part D Up to two aids per year |
Eye wear |
$125 allowance every 2 years with Part D |
Out of network coverage |
30%; $2,500/yr max |
$75 reward per year |
|
SilverSneakers fitness program - fitness center membership benefits |
|
myVisitNowSM Access 24/7 online doctor visits using a computer, tablet, or smart phone. |
$15-$30 |
$240 allowance per year for preventive dental services |
** Note: If you do not join a Medicare Part D plan when you first become eligible, or do not have coverage as good as Medicare's (creditable coverage) you may have to pay a penalty if you join Part D at a later date.
Part D Prescription Drug Coverage (for Preferred Gold with Part D) |
||
---|---|---|
Find a Drug - 2018 Comprehensive Medicare Part D Covered Drugs (Formulary)
Preferred Gold with Part D offers the convenience of both medical and Part D prescription drug coverage together in one plan. Do not join a separate Part D plan for your prescription drug coverage. If you do, Medicare will disenroll you out of your MVP plan.
MVP's coverage for medically necessary Medicare Part D approved drugs includes: |
||
Initial Coverage Stage |
Retail Pharmacy (30 day supply) |
CVS Caremark Mail Order |
Tier 1 - Preferred Generic Drugs |
$0 |
$0 |
Tier 2 - Generic Drugs |
$10 |
$20 |
Tier 3 - Preferred Brand Name Drugs |
$35 |
$70 |
Tier 4 - Non-Preferred Brand Drugs |
36% |
36% |
Tier 5 - Specialty Drugs |
33% |
Not Available |
Not all Part D drugs are available through the mail. |
||
Coverage Gap Stage |
Once your total drug expenses in 2018 reach $3,750, you will pay 44% for generic drugs, 35% for Medicare-contracted brands, 100% for non-Medicare contracted brands. You will continue to pay $0 for Tier 1 drugs. |
|
Catastrophic Coverage Stage |
When you have paid $5,000 out of pocket in 2018, your cost for prescriptions is reduced to the greater of 5% or $3.35 for generics and $8.35 for brand-name drugs. |
|
Part D drugs excluded from our Formulary must go through an exception process in order to be covered. If they are approved, they will be covered in Tier 4. |
||
Non-Part D drugs are not covered. |
||
Note: Costs for Part B drugs and supplies are 20%. Drugs purchased outside the U.S. are not Medicare approved and are not covered. |
HMO-POS members may see doctors within and outside the MVP network. However, with the exception of emergencies or urgent care, it will cost more to get care from out-of-network providers. You must use network pharmacies to access your prescription drug benefit.
Last Updated: October 2017